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Infections and Renal Transplantation

Infections and Renal Transplantation . Lewis McCurdy MD ID Consultants May 23, 2011. Overview. Infections and rejection are the most common complications of transplantation Type of infections differ depending on type of transplantation

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Infections and Renal Transplantation

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  1. Infections and Renal Transplantation Lewis McCurdy MD ID Consultants May 23, 2011

  2. Overview • Infections and rejection are the most common complications of transplantation • Type of infections differ depending on type of transplantation • Type of infection is dependent on patient’s past history and associated risk factors • Timing of infection dependant on level of immunosuppression

  3. How do the infections occur? • Reactivation or recurrence of prior infection • Viral infections • Urinary tract infection • Hospital acquired infection at time of organ transplant • Surgical site infection • Urinary Tract infection • Exposure to nature’s microbes under immunosuppression • Moulds, mycobacteria

  4. Different Infections for Different Organs Transplanted Type of Txplant Infxn per Patient Bacteremia Fungus Most common site Kidney 0.98 5% 0% Urinary tract Heart 1.36 13% 8% Lung Heart-Lung 3.19 45% 23% Lung Liver 1.86 19% 23% Abdomen/Biliary Mandell et al. Principles and Practice of Infectious Diseases.

  5. Types of Infections • Bacterial • Most common following surgery • Atypical infections occur late following transplant • Listeria, mycobacterial • Fungus • Candida • Cryptococcus • PCP (Pneumocystis carinii • Viral • Hepatitis B and C • Herpes family • Cold sores (HSV), shingles (VZV) and CMV • Polyoma • BK and JC virus

  6. Bacterial Infections • Most common is UTI • High risk related to GU surgery • Ureteral anastomosis • Postoperative stent • Often patients have history of UTIs preceding transplant • Indwelling Foley catheters • Leading cause of bacteremia following renal transplant

  7. Increase in Multidrug Resistant Organisms (MDRO) • Mechanisms of resistance • Beta-lactamases • Carbapenemases • Quinolone resistance • Often resistant to oral antibiotics • Po Fosfomycin • IV Ertapenem, Colistin, Aminoglycosides

  8. Nosocomial Infections • Surgical Site • Catheter related • Indwelling blood catheters • Indwelling urinary catheters • Clostridium difficile • Environmental • Aspergillosis

  9. Fungal Infections • Most common cause is Candida • Urinary tract • Blood stream • Other fungi can cause • Meningitis- Cryptococcosis • Pneumonia -Aspergillus, Mucormycosis, other moulds • Skin nodule- Dermatiaceous moulds, Blastomycosis, Histoplasmosis

  10. Virus: Before and After

  11. Herpes Viruses • Herpes 1 and 2 • Cold sores • Genital ulcers • Varicella • Shingles • Epstein-Barr • Mononucleosis and Post-transplant lymphoproliferative disease • CMV • Hepatitis • Diarrhea or intestinal ulcers • Anemia, low white cells, low platelets

  12. CMV disease • Levels of CMV virus can be monitored in the blood • Potentially allows for detection of virus before illness • Patients who have never been exposed are at greatest risk (antibody negative) • Patients who have been previously infected (50-80%) can reactivate

  13. CMV • Most commonly occurs within the first 6 months following transplant • Higher incidence in patient’s with stronger immunosuppression • Associated with rejection • Patients who receive steroids and increase in immunosuppression are at risk for CMV independent of time from transplantation

  14. CMV Prevention and Treatment • New treatments in the last decade • IV and oral formulations now • Ganciclovir (Cytovene) and valganciclovir (Valcyte) • Patients who have no antibody to CMV at transplant receive prophylaxis if donor organ is CMV + • Patients with CMV antibody are followed with CMV levels every 2 weeks and treated if number reaches a certain level

  15. Polyoma Viruses • Most common after renal transplant is BK • Common cause of renal nephropathy • Can lead to allograft dysfunction • Difficult to treat • Cidofovir • Ciprofloxacin • Leflunomide • Reduce immunosuppression • Monitored by PCR • Blood or urine

  16. Prevention • Occurs before and after transplant • High risk patients need to be screened by ID • Screening for prior illnesses • Up to date immunizations • Pneumovax (pneumonia vaccine) every 5 years • Influenza (flu vaccine) yearly • Hepatitis A/B vaccine one series • Prophylaxis antibiotics • TMP-SMX • Valcyte (valganciclovir)

  17. What personal habits effect risk of infections? • Sick exposures • Hobbies • Gardening, Hunting, Fishing • Prior residences • Travel history and future travel

  18. Common Sense Prevails • Wash hands • Avoid sick contacts • Wash food • Cook food AND

  19. Summary • Infections are common after transplant • Risk factors prior to transplant • Postoperative infections • Immunosuppressant related infections • Preoperative screening imperative to reduce immunization preventable disease • Postoperative prophylaxis especially CMV • Common sense prevades all • Infection can kill

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